Commercial Account Application

Name of Business *

Street Address *

Mailing Address (if different)

City *

State/Province *

ZIP / Postal Code *

Phone *

Email Address *

Business License/Resale Number *

Add Tax *YesNo

Contractor License Number *

Bond Number *

Federal ID Number *

Name of Financial Institution *

Account Number *

Accounts Payable Supervisor *

Phone *

Desired Credit Limit *

What is your intended use of a Midstate Co-op Account? *Please check all applicable optionsStore/Irrigation PurchasesAgronomyFuel StationFurnace or Stove Oil DeliveryBulk Propane DeliverySet or Swap Propane Tank

Size of Tank

Would you like a Midstate Co-op fuel card? *YesNo

If yes, how many cards?

4-Digit Pin

As applicable, list name(s) and addresses of corporate officers, partners, and/or owners:

Name

Phone

Social Security Number

Street Address

City

State/Province

ZIP / Postal Code

Name

Phone

Social Security Number

Street Address

City

State/Province

ZIP / Postal Code

Within the past five years, have you or any other owner or officer declared personal bankruptcy or been an owner or officer in a company which declared bankruptcy or otherwise sought the protection of the bankruptcy code?

If yes, what state?

When Filed?

Where Filed?

Name in which the petition was filed?

Does your business have any unpaid taxes, Employment Security, or Labor & Industries? *YesNo

Does your business have notes or other indebtedness past due or past maturity? *YesNo

Does your business have any lawsuits pending or judgment unpaid? *YesNo

Please list three trade references:

Name *

Phone *

Email Address *

Name *

Phone *

Email Address *

Name *

Phone *

Email Address *

Credit Policy and Terms of Sale

This document constitutes a contract between Midstate and the undersigned customer. Accounts are due and payable in full on or before the 15th day of each month. The right to buy goods and services on credit may be suspended at the discretion of Midstate Coop, if the account is not paid in full by the 15th of each month. A late charge of 1.5% per month or 18% per annum will be assessed on all past due accounts. Further, it is understood that all payments received, or credits given, will be applied first to the finance charges and then to the principal balance due. In the event the customer pays with a credit card and the credit card transaction results in a fee to Midstate, Midstate is authorized to pass on the fee to the customer. Midstate Co-op reserves the right to discontinue sales or services to past due accounts and claim any labor or material liens provided or allowed by law. Should default be made in the payment of any installment of principal or interest, then the entire unpaid principal, together with interest due thereon, shall immediately become due and payable at the option of Midstate Co-op. The undersigned customer understands, agrees and promises to pay its account in full according to the above Credit Policy and Terms of Sale. If however, this account is not paid, a collection agency as Midstate Co-op deems necessary, may be instituted and the undersigned customer agrees to pay in addition to the amount of the account, plus interest, reasonable attorney fees and costs of collection, whenever Midstate Co-op engages an attorney or a collection agency to collect a past due account. The venue of any lawsuit to collect debt arising under this agreement will be in Kittitas County, Washington.

In addition, if this is a commercial transaction, then customer agrees to pay additional to the amounts identified above, collection reasonable costs and fees including a contingency collection fee in the event this account and the debt owing on this account are turned over to a collection agency.

The undersigned customer authorizes Midstate to obtain any information Midstate deems necessary to verify the information provided in this credit application including, but not limited to, a credit check.
Typing names below are deemed original signatures.

By checking this box, you are agreeing to the policy and terms of sale. *I agree

Personal Guaranty

The undersigned has carefully read the foregoing continuing Credit Application and understands the contents thereof.

The undersigned agrees to the above terms and conditions stated and assumes personal liability and guarantees payment of the account. The undersigned understands credit will not be extended to the above-named applicant without this personal guaranty.

Name *

Name of Spouse

By checking this box, you are agreeing to the personal guaranty. *I agree

Cardtrol Agreement

Patron acknowledges they have received instructions as to the proper use of the dispensing equipment, the location of the emergency shutoff switch and the use of fire extinguishers. Patron acknowledges that they have received instructions and understand how to use the Cardtrol system. Patron further acknowledges that they have read and understand the emergency procedures.
Patron further agrees not to let anyone who has not been instructed by the Cooperative’s Manager, or a person so designated by the Manager, use such equipment in the use of the dispensing equipment. If your card is lost or stolen, please notify us IMMEDIATELY.
Patron agrees not to leave the dispensing equipment unattended at any time while it is being operated and to accept the responsibility of controlling sources of ignition. Patron further agrees not to dispense Class 1 liquids (i.e., petroleum products) into containers not in compliance with Fire Codes.
Patron agrees to pay for their account in full no later than the 15th of the month following receipt of the Cooperative’s statement. Patron understands that their card may be locked out and no further purchases can be made if their account becomes delinquent. Patron also understands that the price to be paid for fuels dispensed may vary and may be changed without notice by Cooperative. Midstate Co-op is not responsible for lost, stolen or misuse of the Cardtrol card. Patron is responsible for all charges on card(s) until reported to the office personnel at 410 W 3rd Avenue or 509-925-3171.
Patron understands and agrees that any violation of the terms of this Agreement shall constitute authority for the Cooperative to immediately and without notice terminate this Agreement and the use of the facilities herein described. Patron may also terminate this Agreement at any time by the return of the Cardtrol operating card to Cooperative with payment in full for petroleum purchased.
Should you encounter a flammable liquid spill that could be a fire hazard or in any way that threatens the environment, DO NOT HESITATE TO PHONE 911 IMMEDIATELY. If such an event does occur, immediately turn off your engine and observe the “No Smoking” signs.
In the event the customer pays with a credit card and the credit card transaction results in a fee to Midstate, Midstate is authorized to pass on the fee to the customer.

Name *

By checking this box, accept the cardtrol agreement. *I agree

Patron Consent

I hereby consent to include in my gross income, as now or hereafter provided in the Federal Income Tax Laws, the stated dollar amount of cash dividend and/or written notice of allocation which I receive from Midstate Co-op, Ellensburg, WA with respect to my patronage occurring during the current and all subsequent taxable years of this cooperative. This patron consent shall be revocable by me at any time if in writing.

Name *

Doing Business As (if applicable)

Social Security Number *

Employer Identification Number *

Street Address *

City *

State/Province *

ZIP / Postal Code *

By checking this box, you are agreeing to the patron consent. *I agree

Please fill out this W-9

Please Upload Your W-9 *

No file chosen

Customer Information:

Customer Phone *

Name *

Customer Number *

Email Address *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Who is allowed to sign on your account: *

What is your preferred way to receive invoices/statements/payment receipts? *EmailMail